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MAINE HOMELESS MANAGEMENT INFORMATION SYSTEM
AUTHORIZATION FOR DISCLOSURE OF HEALTH AND/OR PERSONAL INFORMATION
(Last Name) (Date of Birth)
READ FIRST: _______________ ("Participating Agency") participates in a federally funded Maine State
Housing Authority ("MaineHousing") program for persons who are homeless. Such participation includes
collecting and entering into a Maine Homeless Management Information System ("HMIS") certain personal
and demographic information Participating Agency maintains for homeless persons it serves, and such
information can also include health care information (such as needs assessment information used to establish
your level of housing needs and services) if Participating Agency is a licensed health care provider.
Information entered and maintained in the HMIS about you can then be accessed and used by
MaineHousing and other participating agencies to evaluate outcomes and the effectiveness of
MaineHousing’s program in reducing homelessness. Authorizing Participating Agency to collect and enter
into the HMIS personal and health care information about you may reduce or eliminate the need for you to
be screened repeatedly by each participating agency from which you seek services (i.e., minimize the number
of times you have to "tell your story"), allow you to receive services more quickly, and enhance
MaineHousing's and participating agencies' ability to provide you with more effective coordinated services to
meet your housing needs. If you wish to authorize Participating Agency to disclose your personal and/or
health care information to MaineHousing and other participating agencies through the HMIS, please
complete and sign this form. Participating agencies who are "covered entities" under HIPAA, may use and
disclose your health care information only for purposes authorized by the federal HIPAA Privacy Standards
and applicable Maine health care confidentiality law, pursuant to this authorization, and pursuant to each
participating agency's own Notice of Privacy Practices, which is posted at each participating agency and
should be offered to you by each participating agency from which you obtain services.
By signing below, I acknowledge, understand and agree that:
My and my dependent children's (identified below) personal and health care information and records are protected by
federal and state laws and regulations governing the confidentiality of client records and cannot be disclosed without
my written authorization unless otherwise provided for in such laws and regulations. All agencies that participate in
the Maine HMIS have an obligation to keep confidential my personal information, identifying information, records,
and any health care information, they maintain about me and my dependent children as listed on this form below.
Unless I strike out this sentence, I intend for this authorization to include disclosure of (i) any mental and behavioral
health information maintained by any participating agency that is a licensed mental health agency, facility or
program (which I have the right to review at any reasonable time before deciding to authorize its disclosure on this
form); (ii)any mental and behavioral health information related to mental health services provided to me by licensed
mental health professionals (i.e., psychiatrists, psychologists, clinical nurse specialists, social workers and counseling
professionals) at a participating agency; and (iii) any HIV information maintained about me by any participating
agency (which disclosure of HIV information could have adverse consequences, including loss or denial of
employment, health insurance benefits, life insurance benefits, and other forms of discriminatory treatment,
whether lawful or unlawful).
Unless I strike out any of the following, I intend this authorization to include (i) the disclosure of records and
information the disclosing agency has received from other agencies, healthcare providers or facilities, and (ii)
subsequent disclosures of information that are within the scope of this authorization.
This authorization is also intended to include disclosure of my historical record contained within the HMIS.
I authorize the disclosures permitted by this authorization to be made through the HMIS, by fax, mail or orally, as